Friday, February 7, 2014


Realizing the domain of hazards, transgressions into any venture are replete with the unknowns. There lie the risks of “what could be,” rather than “what should be.” The imperatives of knowing the risks do not minimize the potential of something that is not understood or a hazard that is not known to exist.

Humans live in the wild frontier of the Lewis and Clark expeditions. A snake here, a wild boar there and life ends. Health expectations seem to follow such traditions of the unknown. Even though most pathology is well known, the constant exposure to newness and its interaction with the physiology create the “wild boars.”


Mitigating risks is the overall desire of all physicians when they undertake the cause of healing. No, it cannot simply be “do this and that will happen.” One has to think the minutia of so many iterant that the multiprocessing brain through experience is most times able to eek out the right answer. And here lies the bleeding reason where not all decisions given the human capacity, are correct. The risks are both from the disease, that compels towards injury and directed medical therapy that has an embedded intolerance to the functions of the individual cell. The balance that permeates between the two is what is considered “success.”

While considering all the nuances of most known risk factors that might rear their ugly heads, a physician then also has to consider the capacity of the patient to relate to the risk of the proposed therapy. For instance, is the treatment more harmful than the disease it is purported to eliminate? Is the individual able to withstand the side effects of the therapy or is he or she in a weakened state of being and that even though the therapy is the correct one with the most benefit, yet the weakened state of the individual, would of necessity certainly endanger the patient. One might also then consider weather the short term benefits of the therapy create the long-term collateral side effects and that whether such a therapy may well not be employed and a lesser or no therapy (placebo) be employed? These are questions of great concern both to the patient and to the physician. As the science of medicine has shown us that the overall benefit has to consider the underlying risk and the capacity of the patient to withstand such therapy. Additionally such proposed therapy should be considered only when short-term benefits do not outweigh the long-term injury to the patient.


The physiology and neuro-psychology of an individual at play in this interaction of “to do or not to do,” is of immense importance. An individual’s vanishing immunity within from the pain of the affliction has to be considered in the reasoned efforts by the physician. At times the wisps of such relational issues bear significance, in that minimizing therapy of the patient may have more long-term benefits then otherwise. A weak immune system is ripe for coercion from many potentially devastating ailments, including cancer.

" suffer the slings and arrows of outrageous fortune..."


"... whips and scorns of time..."

An appropriate example here would be the short-term benefit of corticosteroids and the implications of secondary infections, osteoporosis and suppression of the adrenal gland function. From a orthopedic point of view, one might also review the overuse of steroids within joint cavities and the untoward effects on the ligament weakness and potential rupture.

The weight of this argument is conceived in the thought that before any therapy is embarked upon, a measure must be established between risk, capacity and the true potential benefit to the patient.


At all times in today’s world of “patient-centric decision-making” the patient is a willing and able decision-maker along with his or her physician. It must be so for the proper and ethical undertaking of the care of the patient. However, here we arrive at the slippery slope of the improper effect of this causal behavior. For instance the right therapy may be rejected by the patient through improper understanding or as a result of the short-term side effects from such therapy. A patients self image and ability to withstand the toxic effects to gain the benefits may be conjured in a most negative light and the potential curative intent may be lost. Is the patient then like the consumer (in business world) always right, no matter what the decision? Thus the implied risk of intolerance to proposed therapy then, accidentally becomes the cause of deviating from a path more profitable to the patient? These questions bear a deeper level of understanding. One cannot simply “cut and paste” with the “one size fits all” mode of reasoning.

Acute illnesses

All diseases fall into the categories of “acute” and “chronic.” The former expressly involves a larger share of suddenness of a deviation from a normal existence. The relative change is both sudden and quite disruptive. It carries with it the burden of a lowered threshold of signs and symptoms, where each symptom is perceived excessive and “life-altering.” The intent of the patient is obvious as is that of the physician; to control and mitigate all such complicating insults. The need is great and the desire even greater. Again, even here a balanced reasoning is needed by both parties to reach appropriate results. A patient with a sudden cough, fever and asthenia yearns in today’s world to get their hands on an antibiotic, anticipating an end to their malaise and other symptoms. The physician in an attempt to please may offer such a band-aid, knowing at all times that such therapy will have little or no benefit, yet with that lurking distrust of the unknown is compelled to acquiesce. Here lie the seeds of discontent to so many future ailments. Excessive antibiotic use, especially of the “next-generation” variety, can and usually does make for selective genetic pressures on the offending viral/bacterial/fungal agents. Thus therapy is laying the foundation of a future debacle for human race needing better and better manipulation of the chemical codes to thwart such mutations in these offending infectious agents.

The likes of MRSA, VRE, mutant TB, E-Coli and the like are a testament to such profligate misuse.

Chronic Illnesses

When chronicity compounds the problem, the patient may over time learn to create various means to accept such changes. For instance a low-grade discomfort in the foot may lead to a imbalance at the spine level and create a discopathy creating symptoms of sciatica and more discomfort. Or a chronic inflammation of the stomach treated with “Tums” may be a harbinger of a Helicobacter Pylori infection that precedes a gastric (stomach) lymphoma or a gastric cancer. Long-term acceptance of a low-grade chronic condition can and will at times lead to a worse outcome. Such patients need to be counseled in appropriateness of care and management. All minor complaints, even trivial ones can lead to a profound discovery that can thwart the risk of greater harm down the road of life.


Lastly we arrive at the core of proper care; Understanding!

No truer knowledge than a reasoned understanding of the ailment both by the patient and the physician will lead to the best outcomes.

A knowledgeable patient asks the right questions and a knowledgeable physicians offers the correct answers to those questions.

We live in a world of fear and reprisal. We must learn the art of managing these fears and by acknowledging their presence, learn to educate against reprisals. The world is a conjugate of many reflections. A proper understanding circumnavigates such a minefield. It is in the learning of the known that measures of ultimate benefit reside, not in the mindless guidelines and mandates that conform to a closed-loop thinking of the few.

Hey, I didn’t say this was going to be easy!

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